MOOD DISORDERS Chapter F1 Anxiety Disorders in Children

MOOD DISORDERS Chapter F1 Anxiety Disorders in Children

MOOD DISORDERS Chapter F1 Anxiety Disorders in Children and Adolescents Ronald M Rapee DEPRESSION IN CHILDREN AND ADOLESCENTS Companion Powerpoint Presentation Adapted by Henrikje Klasen and Julie Chilton

The IACAPAP Textbook of Child and Adolescent Mental Health is available at the IACAPAP website http://iacapap.org/iacapap-textbook-of-child-and-adolescentmental-health Please note that this book and its companion powerpoint are: Free and no registration is required to read or download it This is an open-access publication under the Creative Commons Attribution Noncommercial License. According to this, use, distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited and the use is non-commercial. Anxiety Disorders in Children and Adolescents Outline The Basics

Description and diagnosis Comorbidity Epidemiology Assessment Risk and maintaining factors Treatment Prevention and early intervention Anxiety Disorders in Children and Adolescents The Basics

Internalizing Disorders Once thought to be rare and low impact More studies recently Focus on: Generalized Anxiety Disorder (GAD) Social Anxiety Disorder Specific Phobias Anxiety Disorders in Children and Adolescents Description and Diagnosis

Avoidance = core feature Also: fearfulness, distress or shyness Expectation of threat Worry Rumination Anxious anticipation Negative thoughts Physical complaints Difficulty with sleep Anxiety Disorders in Children and Adolescents Comorbidity Much overlap between the various anxiety

disorders Overlap between anxiety and depression 80-90% have more than one disorder 75% have more than one anxiety disorder 10-30% have additional mood disorder 25% of the younger children have an additional behavioral disorder Overlap with alcohol abuse appears later Anxiety Disorders in Children and Adolescents Epidemiology: Prevalence Variable across countries and studies ~5% in Western populations Prevalence:

Highest rates for specific phobias Moderate for separation anxiety, generalized anxiety, social phobia Lower for obsessive compulsive disorder Lowest for post traumatic stress disorder Anxiety Disorders in Children and Adolescents Epidemiology: Gender distribution General Population: females>males As much as 1.5-2 x F>M Difference appears as young as 5 years of age In treatment seeking populations in Western

societies M=F Anxiety Disorders in Children and Adolescents Age of Onset Some of the earliest disorders to appear Begin by mid childhood to mid adolescence Association with temperamental inhibition and fearfulness Average ages of onset: Animal phobias ~ 6-7 yrs Separation anxiety d ~7-8 yrs GAD ~ 10-12 yrs Social anxiety d ~ 11-13 yrs OCD ~13-15 yrs

Panic d ~ 22-24 yrs Anxiety Disorders in Children and Adolescents Course Among the most stable Little spontaneous remission Increased risk in adolescence: Anxiety and mood disorders Increased risk in adulthood: Anxiety and mood disorders Substance use Suicide

No association with family size, parental marital status, educational attainment, intelligence Anxiety Disorders in Children and Adolescents Assessment: General 3 Parts: Questionnaires, diagnostic interview, behavioral observation Use clinical judgment to combine information from various sources Separate interview with children > 8yrs old Anxious kids fake good Anxious parents may exaggerate symptoms Identify motivation behind behaviors

Determine primary disorder and treat first Anxiety Disorders in Children and Adolescents Assessment: Questionnaires

Spence Children's Anxiety Scale (SCAS) Screen for Child Anxiety Related Disorders (SCARED) Multidimensional Anxiety Scale for Children (MASC 2) Preschool Anxiety Scale Revised (PASR) Revised Childrens Manifest Anxiety Scale (RCMAS) State Trait Anxiety Inventory for Children (STAIC) Beck Anxiety Inventory for Youth Childrens Moods, Fears and Worries Fear Survey Schedule for Children Revised (FSSC-R)

Social Phobia and Anxiety Inventory for Children (SPAIC) Social Anxiety Scale for Children-Revised (SASC-R) Childrens Anxiety Sensitivity Index (CASI) Childrens Automatic Thoughts Scale (CATS) School Anxiety Scale-Teacher Report (SAS-TR) Childrens Anxiety Life Interference Scale (CALIS) Anxiety Disorders in Children and Adolescents Assessment: Diagnostic Interview Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) http ://www.psychiatry.pitt.edu/node/8233 Developmental and Wellbeing Assessment

(DAWBA) http://www.dawba.com Diagnostic Interview Schedule for Children (DISC) Anxiety Disorders Interview Schedule for Children (ADIS-C) Preschool Age Psychiatric Assessment (PAPA) Anxiety Disorders in Children and Adolescents Risk and Maintaining Factors Family transmission: Anxiety and inhibited temperament runs in families 1st degree relatives at risk for anxiety and

mood disorders Transmission of specific disorders have some specificity Genetic and environmental influences Anxiety Disorders in Children and Adolescents Risk and Maintaining Factors Genetic Factors: ~40% variance mediated by genetics Twin studies show 30-40% variance by heritability Especially high with general neuroticism Most studied is 5HTTLPR gene 2 short alleles on 5HTT gene increase

environmental responsiveness Anxiety Disorders in Children and Adolescents Risk and Maintaining Factors Temperamental Factors: Best studied and most clearly established risk factorinhibitioninhibition

Withdrawal in face of novelty Lack of smiling Lack of talk Limited eye contact Close proximity to attachment figure Slowness to warm up to strangers or peers Unwillingness to explore new situations Inhibited preschool kids 2-4x more likely to have anxiety by middle childhood Anxiety Disorders in Children and Adolescents Risk and Maintaining Factors

Parent and family factors: Evidence difficult to obtain Data not consistent Parenting characteristics: Overprotection Intrusiveness Negativity Parental modeling and communication of fear Sexual abuse, physical abuse, family violence Anxiety Disorders in Children and Adolescents Risk and Maintaining Factors Life Events:

Increased negative life events Greatest difference on dependent events Bullying and teasing Neglect and rejection by peers Anxiety Disorders in Children and Adolescents Risk and Maintaining Factors Cognitive Biases: Heightened threat beliefs and expectations Specific to disorder type Decrease with successful treatment Bias in attention toward threat Bias to interpret ambiguous info as threat

Anxiety Disorders in Children and Adolescents Treatment Psychopharmacology: Selective Serotonin Reuptake Inhibitors (SSRIs) Most studies focus on OCD Little difference between agents, except paroxetine not recommended Treatment generally 10-15 weeks 50-60% children respond vs 30% placebo Medication effects may level off after 8 weeks 7% anxious kids discontinue due to adverse side effects Monitor for suicidality Anxiety Disorders in Children and Adolescents

Treatment Skills-based programs: Psychoeducation Relaxation Exposure Contingency management Parent training Cognitive restructuring Social skills and assertiveness training Generally 8-15 weeks 1-2 hours/session Group or individual

http://www.adaa.org/resources-professionals/podcas ts/what-parents-need-know-about-treatment-children -with-anxiety-disord Anxiety Disorders in Children and Adolescents Treatment: Skills-Based Programs Anxiety Disorders in Children and Adolescents Prevention and Early Intervention Universal programs Broad emotional health Small but meaningful effect sizes

Selective programs https://www.youtube.com/watch?v=8pyanIgSJuw&feature=relmfu Increased risk but no diagnosis Moderate effect sizes Indicated programs High score on risk factors like temperament Cool Little Kids for high parent anxiety Anxiety Disorders in Children and Adolescents Conclusion Promising areas for growth:

Longitudinal research for risk factors Gene-environment interactions Peer interactions Dissemination of treatments Evaluation of novel developments Anxiety Disorders in Children and Adolescents Thank You!

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